Family doctors caught in middle in deadly opioid crisis, London study finds

Family doctors are exhausted and overwhelmed by the opioid drug crisis, dealing with patients with chronic pain while being hyper-vigilant about how they prescribe the powerful painkillers, London researchers say.

The findings add a new layer to the fallout of the deadly crisis, whose toll is seen often in Southwestern Ontario by ambulance crews, police and addiction workers.

Researchers at Western University and in Toronto and Montreal interviewed and observed 27 family doctors and primary care nurses in northern, rural and urban centres, including London. Across the board, the health care workers reported treating patients with chronic pain – especially ones who also were living in poverty – was, at best, challenging and, at worst, frustrating and overwhelming.

“They’re deeply concerned about what they’re seeing with their patients, not just the medical conditions like chronic pain, but patients who are also dealing with addictions, mental health issues or poverty,” said Fiona Webster, lead author and health sciences professor at Western University.

“It’s that constellation of factors that’s causing the most stress on them, certainly in the stories they shared with us.”

Though the hyper-potent synthetic opioid fentanyl, often made in clandestine labs, is implicated in many overdose deaths, prescription painkillers – abused by patients or diverted to the streets – play a role in the opioid crisis, too.

In London, the prescription opioid hydromorphone is the most popular drug crushed and injected on the streets. A 2018 national study, found more than half the opioid overdose deaths in 2016 involved prescription drugs. A third of the deaths involved people with an active opioid prescription.

The spate of apparent opioid overdoses, which have killed more than 10,300 people across Canada between January 2016 and September of last year, have prompted the medical community to take a critical look at opioid prescribing habits.

London hospitals are implementing a new protocol for patients with non-chronic pain including fractures, broken fingers, acute appendicitis or tonsillectomies. Under the new policy, people would get a maximum three-day supply of opioid pills.

In Ontario, opioid prescriptions are tracked by the narcotics monitoring system. Doctors in Ontario may be concerned they’ll be disciplined if they improperly prescribe the addictive painkillers, Webster said.

“Physicians are under a lot of pressure not to prescribe opioids,” said Webster. “This has created an untenable situation for physicians where they’re really cast more into the role of having to be suspicious of their patients. It’s a constant worry in the back of their minds.”

Doctors can recommend alternative pain-relief strategies – including massage therapy or physiotherapy – but the out-of-pocket services may be out of reach for impoverished patients, Webster said.

“They come with a price and they’re not covered under our public health insurance system. The doctor is in this very difficult position of not being able to help their patients who have chronic pain and aren’t able to afford alternative therapies,” Webster said.

The inability to connect patients, especially ones from vulnerable populations, with the resources they need for healthy lives is troubling for many primary care providers, said Sharad Rai, a family doctor and president of the London and District Academy of Medicine.

“We’re in a situation where we’re under-resourced and patients are suffering,” he said. “As the London and District Academy of Medicine, we’re trying to bring attention to these issues and trying to correct some of these chronic issues in patient care.”

The nurses and doctors in the study reported feelings of helplessness, loss of job satisfaction and emotional exhaustion from trying to care for these patients, key symptoms of workplace burnout.

Webster said the study findings, and the overwhelming pattern of responses among the doctors and nurses interviewed, should prompt policymakers to invest in more training for physicians and more resources for complex patients dealing with chronic-pain, mental health issues, addiction or poverty.

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